Anatomic Snuffbox (Distal Radial Artery) and Radial Artery Access for Treatment of Intracranial Aneurysms with FDA-Approved Flow Diverters

Abstract

BACKGROUND AND PURPOSE: Transradial access for neurointerventional procedures has been proved a safer and more comfortable alternative to femoral artery access. We present our experience with transradial (distal radial/anatomic snuffbox and radial artery) access for treatment of intracranial aneurysms using all 3 FDA-approved flow diverters. MATERIALS AND METHODS:This was a high-volume, dual-center, retrospective analysis of each institution's data base between June 2018 and June 2020 and a collection of all patients treated with flow diversion via transradial access. Patient demographic information and procedural and radiographic data were obtained.RESULTS: Seventy-four patients were identified (64 female patients) with a mean age of 57.5 years with a total of 86 aneurysms. Most aneurysms were located in the anterior circulation (93%) and within the intracranial ICA (67.4%). The mean aneurysm size was 5.5 mm. Flow diverters placed included the Pipeline Embolization Device (Flex) (PED, n ¼ 65), the Surpass Streamline Flow Diverter (n ¼ 8), and the Flow-Redirection Endoluminal Device (FRED, n ¼ 1). Transradial access was successful in all cases, but femoral crossover was required in 3 cases (4.1%) due to tortuous anatomy and inadequate support of the catheters in 2 cases and an inability to navigate to the target vessel in a patient with an aberrant right subclavian artery. All 71 other interventions were successfully performed via the transradial approach (95.9%). No access site complications were encountered. Asymptomatic radial artery occlusion was encountered in 1 case (3.7%).CONCLUSIONS: Flow diverters can be successfully placed via the transradial approach with high technical success, low access site complications, and a low femoral crossover rate. ABBREVIATIONS: CCA ¼ common carotid artery; dRA ¼ distal radial artery; FD ¼ flow diverter; RA ¼ radial artery; TRA ¼ transradial access T he transradial access (TRA), including distal radial artery (dRA) access in the anatomic snuffbox and radial artery (RA) access at the palmar surface of the wrist, is being increasingly used as primary vascular access for neurointerventional procedures. In prior years, large randomized trials in the field of interventional cardiology and more recent articles in neurointerventional surgery have shown higher patient preference for the TRA, cost reduction, as well as lower morbidity and mortality compared with the traditional transfemoral access (TFA). 1 -11 Reduction in access site complications has been a particular advantage of wrist over femoral access and is an important consideration for vascular access choice in the treatment of intracranial aneurysms using flow diversion. Patients undergoing flow diversion are required to take dual-antiplatelet agents and receive heparin during the procedure, all of which increase the risk of bleeding from the access site. 12 Also, flow diverters (FDs) may require large-bore catheter assemblies for delivery and deployment, which may increase the risk of radial artery occlusion, access s...

Feasibility and Safety of Flow Diversion in the Treatment of Intracranial Aneurysms via Transradial Approach: A Single-Arm Meta-Analysis

“…After duplicate removal and abstract screening, 13 studies remained for full-text screening. After reading the full text, we included 8 studies (11)(12)(13)(14)(15)(16)(17)(18) in the meta-analysis. The 8 studies involved 265 FD-treated aneurysms via TRA in 250 patients.…”

“…The vessel tortuosity was the most common reason (45.5%), followed by radial artery spasm (27.3%), left common carotid artery (LCCA) angle of origin (18.2%), and inadequate support (4.5%) and aberrant right subclavian artery (4.5%). In one study ( 14 ), two cases were converted to femoral artery pathway because of vascular tortuosity and insufficient support. We think that it was caused by vascular tortuosity.…”

“…The access-related complications include radial artery spasm and radial artery occlusion. Complications occurred in four of these studies (12,14,16,17). Based on the meta-analysis of fixed effects, the access-related complications rate was 1% (95% CI 0-0.03; I 2 = 0.00%; p < 0.01; Figure 3).…”

“…The average age of the 8 studies included was 55-62.1 years. Six studies (11)(12)(13)(16)(17)(18) reported the laterality of aneurysms, 57.1% (92/161) of which were located on the left side and 7 studies (11)(12)(13)(14)(15)(16)(17) reported that 91.5% (238/260) of aneurysms were located in the anterior circulation. The 8 studies described in detail the use of drugs and operative procedures before operation.…”

Therapeutic efficacy and complications of radial versus femoral access in endovascular treatment of unruptured intracranial aneurysms

“…A literature review limited to the treatment of intracranial aneurysms via TRA similarly demonstrated low incidences of minor ASCs, ranging from 0% to 5.0% (Table 4). 4,5,7,13,30,31,39,40,[43][44][45][46][47][48][49] TRA can be expected to reduce minor ASCs.…”